Appeals & Grievances

If you would like to send a complaint request directly through Medicare, you can do so on the Medicare website by submitting https://www.medicare.gov/MedicareComplaintForm/home.aspx  .

If you have a problem or complaint (grievances, coverage decisions, appeals), please call us first. Your health and satisfaction are important to us. When you have a problem or concern, we hope you will try an informal approach first: please call Navigation Services at (503)-345-5702 or 1-866-798-2273. We will work with you to try to find an acceptable solution to your problem.

Refer to the How to sections below.

Grievances or Complaints

Grievances or complaints about quality of care, waiting times, and the customer service you receive are examples of the kinds of problems handled through this process. Calling Navigation Services is the first step or you may put your complaint in writing and send it to us. You will find information about Grievances in Chapter 9 of the MyPlan C, A and E Evidence of Coverage or in Chapter 7 of the MyPlan C, A and E Evidence of Coverage. The information is also available by clicking the icon below.

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How to obtain an aggregate number of appeals, grievances and exceptions:
For information about the aggregate number of grievances, appeals and exceptions that have been filed with FamilyCare Health Plans, contact Navigation Services at 1-866-798-CARE (2273) (TTY 1-800-735-2900) 8 am–8 pm, seven days a week.

Phone number for questions about appeals, grievances or exceptions:
If you have questions about appeals, grievances or exceptions, contact Navigation Services at 1-866-798-CARE (2273) (TTY 1-800-735-2900) 8 am–8 pm, seven days a week. This includes questions about how to file an appeal, grievance or exceptions, or questions about the status of an appeal, grievance or exception.
 

Appoint a Representative

If a beneficiary would like to appoint a person to file a grievance, request a coverage determination or exception, or request an appeal on his or her behalf, the beneficiary and the person accepting the appointment must fill out form CMS-1696 (or a written equivalent) and submit it with the request.

Click on the icon to view the form CMS-1696: 

Coverage Decisions 

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. This is the process you use for issues such as whether something is covered or not and the way in which something is covered. Please call Navigation Services at (503)-345-5702 or 1-866-798-2273 or contact us in writing. You will find information about Coverage Decisions and Exceptions in Chapter 9 of the MyPlan C, A, E Evidence of Coverage or in Chapter 7 of the MyPlan C, A and E Evidence of Coverage. The information is also available by clicking the icon below.

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How to Appeal a Coverage Decision

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. You can contact us in writing or by phone to make a complaint or an appeal. To contact us by telephone, call Navigation Services, Monday through Friday from 8 am to 8 pm toll-free at (503)-345-5702 or 1-866-798-2273, TTY 1-800-735-2900. You will find information about Appeals in Chapter 9 of the MyPlan C, A and E Evidence of Coverage or in Chapter 7 of the MyPlan C, A and E Evidence of Coverage. The information is also available by clicking the icon below.
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Request for a Medicare Prescription Drug Coverage Determination

A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this Medicare coverage determination model form to request an initial coverage determination (decision) on a Medicare Part D medication that requires prior authorization from FamilyCare Health Plans. 
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Request for Redetermination of Medicare Drug Denial

If a Medicare Part D medication was initially denied, a beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this Medicare redetermination model form to request a redetermination (appeal) with FamilyCare Health Plans.  
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Quality Improvement Organization

Each state employs a Quality Improvement Organization. In Oregon the Quality Improvement Organization is called Acumentra Health. Acumentra Health provides a group of doctors and other health care professionals who are paid by the Federal government. Acumentra Health is funded by Medicare to check on and improve the quality of care for people with Medicare. You should contact Acumentra Health if you have a complaint about the quality of care you have received, or if you think coverage for your hospital stay, home healthcare, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) is ending too soon. You can contact Acumentra Health at (503)-279-0100 or in writing at 2020 SW Fourth Avenue, Suite 520, Portland, OR 97201.

If you have a complaint and would like to discuss it with FamilyCare, please contact FamilyCare at 1-866-798-CARE (2273), TTY users call 1-800-735-2900, Monday to Friday from 8 am - 8 pm. If you would like to send a complaint request directly through Medicare, you can do so on the Medicare website by submitting a Medicare Complaint Form.

Please click here to view the PDF with more information.

• The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, co-payments and restrictions may apply. Benefits, formulary, pharmacy network, premiums and/or co-payments/co-insurance may change on January 1 of each year.